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DOI: 10.1055/s-2007-981312
© Georg Thieme Verlag Stuttgart · New York
Die Technik der transoralen Divertikulostomie bei Zenker-Divertikeln - Langzeitresultate und Literaturvergleich
Zenker's Diverticulum Treated by Transoral Diverticulostomy: Technique and ResultsPublication History
Publication Date:
01 October 2007 (online)
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Zusammenfassung
Ziel der Untersuchung: Technik und eigene Ergebnisse der transoralen Staplerdivertikulostomie mittels eines modifizierten transoral eingeführten Klammerschneideinstrumentes (Multifire Endo GIA™, Tyco Healthcare) werden in einem Literaturvergleich analysiert. Alternative minimal invasive Verfahren wie Koagulationsverfahren mit CO2-Laser oder Argon-Plasma werden in der Analyse berücksichtigt. Basismethodik: An unserer Klinik wurden seit 1996 31 minimalinvasive Divertikelabtragungen mittels eines transoral eingeführten Klammerschneideinstruments durchgeführt. Alle Patienten wurden prospektiv erfasst und in einem medianen Zeitraum von 54 Monaten evaluiert. Prä- und postoperativ wurden der Gastrointestinale Lebensqualitätsindex sowie ein Dysphagiescore (GHDS) erhoben. Alle Patienten erhielten eine Endoskopie, eine Ösophagus-Funktionsdiagnostik (Manometrie und pH-Metrie) sowie eine Breischluckuntersuchung. Hauptbefunde: Eine signifikante Verbesserung durch den operativen Eingriff wurde anhand des Gastrointestinalen Lebensqualitätsindex sowie des Dysphagiescores nachgewiesen (p < 0,001). Die stationäre sowie Durchzugsmanometrie erbrachte prä- wie postoperativ keine Funktionsstörung des oberen ösophagealen Sphinkters oder der tubulären Speiseröhre. In einem Fall musste wegen einer Speiseröhrendissektion durch Einbringen des Sperrers konvertiert werden. Eine Blutung der Klammernahtreihe wurde intraoperativ durch Clipapplikation gestillt. Eine Zahnprothesenverletzung wurde durch Refixierung behoben. Während des Nachbeobachtungszeitraums (Median: 54 Monate) fielen zwei Patienten mit Rezidiven auf. Schlussfolgerungen: Verglichen mit der konventionellen Operation erscheint die endoskopische Technik risikoärmer, schneller durchzuführen und schonender für die Patienten. Sie verkürzt den stationären Aufenthalt und hinterlässt keine Narben. Die endoskopische Divertikulostomie ist derzeit unser Verfahren der Wahl.
Abstract
Aim of the study: The surgical technique of transoral diverticulostomy by a modified Endo-GIA™ Stapler (Multifire Endo GIA™, Tyco Healthcare) is described. Experiences of this procedure in 31 patients are analysed and compared with different endoscopic and conventional surgical therapies of Zenker's diverticula, which are reported in the literature. Method: From January 1996 to December 2005, 31 transoral diverticulostomies were performed. All patients were included porspectively into the study. The median follow-up time after diverticulostomy was 54 months. Manometry, pH-study of the esophagus, endoscopy and swallow radiography were performed before and after surgery. All patients completed the Gastrointestinal quality of live index (GQLI) and the Großhadern dysphagia score (GHDS). Results: Subjective comfort of the patients as measured by the Smiley Index, the GQLI and the GHDS was increased significantly (p < 0.001) after therapy. Manometry showed that the upper esophageal sphincter fuctioned normally before and after intervention. A gastrografin swallow excluded leakage at the stapler suture-line in all cases. A conversion to a conventional cricomyotomy with resection of the diverticulum had to be performed once due to a dissection of the esophagus that occurred during insertion of the spreader. In one patient a bleeding out of the suture line was successfully treated with a metal clip. A prothesis broke due to the insertion of the spreader. Two patients developed relapses during the follow-up period of 54 months. Conclusion: Compared to standard procedure the endoscopic minimal-invasive therapy proved to be safer. The operation time and the postoperative stay are shorter.
Schlüsselwörter
Zenker-Divertikel - transoral - Divertikulostomie - minimalinvasiv - Lebensqualität
Key words
Zenker diverticulum - transoral - diverticulostomy - minimal-invasive - quality of life
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Dr. med. R. A. Lang
PD Dr. med. T. P. Hüttl
Chirurgische Klinik und Poliklinik · Klinkum der Universität München-Großhadern
Marchioninistr. 15
81377 München
Phone: 00 49 / 89 / 7 09 50
Fax: 00 49 / 89 / 70 95 54 64
Email: Reinhold.Lang@med.uni-muenchen.de
Email: Thomas.Huettl@med.uni-muenchen.de